LOUISIANA INDEPENDENT LIVING ASSESSMENT 3.1 COVER SHEET Assessment Re-Assessment Annual Clients Initials Date: Date: Change Nutrition Score ADL A. Client Identification 12. Are you a Veteran? 1. Name: (First) (MI) (Last) IADLS Yes No 13. Are you a Veteran dependent? Yes Maiden Name: No B. Emergency Contact Also Known as: Primary Physician 2. ID Number Name 3. Ethnic Race a. Non-Minority (White, non-Hispanic) Address b. Black/African-American c. American Indian / Native Alaskan d. Asian e. White Hispanic f. Native Hawaiian/Other Pacific Islander Phone Number Relative/Friend Name Address Phone Number g. Other C. Directions to Home 4. Phone Number 5. Social Security Number# 6. DOB / Month / Day D. Does Client live? Year 1. Alone 2. With spouse/partner 3. With spouse and child a. Street 4. 5. With child/children (including adult child) Information unavailable b. Town 6. With others 7. Age 8. Gender Male Female 9. Mailing Address c. State LA Name of spouse/Partner (Optional) d. Zip E. Health Insurance: Do you have? 10. Residence Yes a. Street or PO Box Type 1. Medicare A b. Town c. State No 2. Medicare B LA d. Zip 11. Marital Status a. Single b. Married d. Widowed e. Divorced 3. Medicare D 4. Medigap c. Separated f. Not Available 5. Medicaid 6. LTC 7. Other Revised 08/02/2005 Clients Initials L. Services F. Do you have prescription drug insurance? Yes Yes No Assisted Transportation Case Management Chore Congregate Meals No G. Client Characteristics Yes No a. Abused/Neglected/Exploited Home Delivered Meals Homemaker Date If yes, Referred to I&A Legal Services b. Disabled c. Duplicate Mail Nutrition Education d. Female head of household e. Frail Nutrition Counseling Outreach Personal Care Transportation Medication Management Wellness f. Homebound g. Medicare Eligible h. Receiving Social Security i. State Resident j. Tribal NFCSP 1 Other H. Household Size (entire household) a. 1 person b. 2 people c. 3 people d. Want to Apply Adult Day Care/Adult Day Health If no, do you want information on the Senior Rx program? Yes No 1 National Family Caregiver Support Program requires a different assessment form. M. Services Client is placed on waiting list? 4 or more people I. Monthly Income: (entire household) SSI $ 565 or less 1 $ 775 or less 2 $1,040 or less 3 $1,305 or less 4 $1,576 or less 5 $1,836 or less Yes No If yes, list services(s) N. Interview Questions Where interviewed: Home Nursing Home Other Hospital (Specify) Did someone help client or answer questions for client? Yes No Helper's Name Relationship Communication/Language Assistance needed for assessment? Yes No Language J. Donations Individual has been advised that s/he has an opportunity to make voluntary and anonymous donations for any service s/he may receive. Yes No Type of assistance Assessor: K. Permission The client has formally authorized a release of information. Yes No Agency: Client signature: Attach copy of signed and dated authorization. 2 Revised 08/02/2005 Clients Initials O. Determine Your Nutritional Health. (Circle your answers and add up your score) Yes No Client has made changes in lifelong eating habits because of health problems. Client eats fewer than two (2) meals per day. Client eats fewer than 5 servings of fruits and vegetables Client eats fewer than two (2) servings of dairy products (such as milk, yogurt, or cheese) every day. Client has biting, chewing, or swallowing problems that makes it difficult to eat. Client does not have enough money to buy food most of the time. Client eats alone most of the time. Client takes three (3) or more different prescriptions or over-the-counter drugs per day. Without wanting to, Client has lost or gained ten (10) pounds in the past six (6) months. Client is not physically able to shop, cook, and/or feed themselves (or to get someone to do it for them) most of the time. Client has three (3) or more drinks of beer, liquor, or wine almost every day. TOTALS (Add YES and NO columns) for your total nutrition score. 0 COMBINED TOTAL Record the combined total on the Cover Sheet and the GOEA Score Sheet. If it is: 0-2 GOOD! Recheck the Nutrional Score at annual review. 3-5 You are at a moderate nutritional risk. Ask your area agency on aging, senior nutrition program, senior citizens center or health department what can be done to improve your eating habits and lifestyles. 6 or more You are at high nutritional risk. Bring a copy of this checklist the next time you see your doctor, dietician, or other qualified health or social service professional. Talk with them about any problems you may have. Ask for help to improve your nutritional health. NOTE: High-risk clients should receive a copy of the scoring sheet and isntructed to give to their physician, caregiver, or family member for follow-up. High-risk clients should be closely monitored - a six-month review. 3 Revised 08/02/2005 Clients Initials SECTION 3.2 INTAKE ASSESSMENT A. Legal Representative 1. Do you have a: Yes No ✔ a. Power of Attorney b. DPOA for Health Care c. DPOA for Finances ✔ d. Representative Payee ✔ e. Guardian 2. Do you have advanced directives? If no, do you need information provided about advance directives? Yes No Yes No B. Assessment Information 1. Reason for Referral 2. Referred by? a. Self d. Agency b. Family e. Other c. Hospital f. Information unavailable (Name) 3. Do you live in (Read all choices before recording the answer) a. House/mobile home b. Private Apartment c. Private Apartment in senior housing d. Residential care home e. Nursing home f. Information unavailable g. Other 4. How long have you lived at this current residence? a. Less than 12 months b. 1 - 3 years c. 3 years or more 5. If you moved in the past 3 years, did you live in? a. Own home for months b. Residential care home for c. Other months for months d. Nursing home for e. Hospital for f. Not applicable months months 6. Are you currently employed? a. Yes b. No 4 Revised 08/02/2005 Clients Initials 7. Are you receiving any of the following services? (Refers to services that may not be funded with GOEA dollars) Services Yes No Want to Apply Services Yes a. Attendant services r. Energy Assistance b. Medicaid Waiver c. Homemaker Program d. Home Health Aide e. Private Nursing s. Telephone Reassurance t. Medicaid u. SSI v. Prescription Program f. Speech Therapy w. OMB/SLMB g. Occupational Therapy h. Physical Therapy x. Medical Alert y. Community Services i. Private Sitter Services z. Respite Services j. Emergency Lifeline 1. Hospice Services k. Senior Companion 2. Rehabilitation Services l. Weatherization 3. Transportation Services m. Home Repair 4. Other n. Support Group 5. Other o. Adult Day Services 6. Other p. Commodity Assistance 7. Other q. Food Stamps 8. Other No (Read all choices before recording the answer) (Arrows and Italics indicate that the question is to be answered by the client only) 8. Do you have any children or other relatives who live nearby (within one hour's drive)? a. b. Yes No *9. Do you have contact with: Yes a. Family often enough b. Friends often enough No 10. Is there a friend or relative who could take care of you for a few days? a. b. Yes No *11. When you make a decision about something, in general, how do you do it? a. By yourself b. By yourself after talking to family/friends c. Follow advice of family/friends d. Let other people make decisions for you e. Information unavailable *12. In rating your health, would you say that it is excellent, good, fair or poor? a. Excellent b. Good c. Fair d. e. Poor Information Unavailable 13. In the past, how many times have you stayed overnight in a hospital? a. Not at all b. One time c. 2 or 3 times d. More than 3 times 14. Have you ever stayed in a nursing home, residential care home or other institution? a. Yes b. No 5 Revised 08/02/2005 Want to Apply Clients Initials 15. Do you have the following conditions? a. Heart problems Y N g. Breathing disorders Y N b. Arthritis Y N h. Cataracts Y N c. Diabetes Y N i. Urinary problems Y N d. Cancer Y N j. Ankle/leg swelling Y N e. Stroke/neurological problems Y N k. Cognitive impairment/dementia Y N f. Mental/emotional condition Y N l. Other Y N *16. If stroke/neurological condition, are you limited in what you can do? Yes No 17. How much of the time does bad health, sickness, pain, or disability stop you from doing things you would like to do? a. Never b. c. Sometimes 18. Have you fallen in the last 3 months? a. d. Often b. Yes Always No 19. How often do you go out of the house/building where you live? a. b. Two or more days a week One day a week or less 20. Do you use a walker or four-pronged cane to get around? a. Yes b. No c. Sometimes c. Sometimes 21. Do you use a wheelchair to get around? a. Yes b. No *22. Could you please tell me what year it is? a. Correct answer b. Incorrect answer *23. What month is it? a. Correct answer b. Incorrect answer *24. Where are we now? a. Correct answer b. Incorrect answer 25. Does client have problems with hearing, vision, or speech that is not corrected with aids such as glasses, hearing aids, etc? Aids/Device Yes No Are aids working in order? a. Hearing e. Hearing b. Vision f. Vision c. Speech g. Speech d. Other h. Other Was a referral made? Yes, to whom Yes No If no, why a referral was not made made. *26. In the past 6 months, have you lost more than 10 pounds without trying? *27. Do you often feel sad or isolated? a. Yes b. No *28. How often do you have contact with persons outside your home? a. Yes b. No If yes, referred to: Daily Weekly Monthly Not often 6 Revised 08/02/2005 Clients Initials 29. How many prescription medications do you take? Without Help 30. Can you: Yes No If No, do you have help? Yes If Yes, is it enough ADL IADLS help? No Yes Comments No a) Get around inside your home b) Bathe c) Dress d) Get in and out of bed/chair e) Use toilet f) Eat g) Manage your money h) Take care of shopping i) Take your medication j) Prepare your meals k) Perform heavy home chores l) Perform ordinary housework m) Use transportation n) Use Telephone Total number of ADLS Total number of IADLS *Record the number of ADLs and IADLs on the Cover Page and number 4 and 5 on the GOEA Score Sheet. Ask Questions 31 and 32 only if it is determined that the client has limitations in ADLS and / or IADLS. 31. Would you like to talk to someone in detail about wheelchairs, walkers, canes, safety rails, ramp, etc. and other devices such as speaker phones with large letters? Yes No If yes, referral made to: Date: 32. Would you like to talk to someone about how your home can be better adapted to help you get around and perform your daily activities? Yes No If yes, referral made to: Date: 7 Revised 08/02/2005 Clients Initials SECTION 3.3 HOME ENVIRONMENT A. Are any of these problems or safety hazards present in your home? 1. ENVIRONMENT CHECKLIST Yes No a. Dangerous stairs/floors b. Difficult to get to home entrance Comments: c. Difficult to get to bathroom/bedroom d. Major appliances/toilet not working e. Problems with heating/cooling f. Problems getting water/hot g. Difficulties keeping home free from odor/pests h. Smoke alarm needed i. Electrical hazards j. Poor lighting k. Unsafe stove l. Loose/slippery rugs m. Inadequate locks for doors/windows n. Difficult to keep home clean/free of clutter o. Other problems? 2. In case of an emergency, such as a fire, do you think you would be able to get out of your house or apartment safely? Yes No 3. In case of an emergency, such as a fire or fall, do you think you could summon help to your home? Yes No Comments 8 Revised 08/02/2005 Clients Initials SECTION 3.4 INFORMAL SUPPORTS 1. FOR THE CLIENT Can you tell me who helps you on a regular basis? Yes No Record information on primary caregiver, as well as other caregivers: Primary Caregiver NAME RELATIONSHIP ADDRES PHONE Day Eve. Other Caregivers NAME RELATIONSHIP PHONE TYPE OF CARE/HELP Day Eve. Day Eve. 2. FOR THE PRIMARY CAREGIVER Yes No Comments a. Personal care (such as help with bathing, dressing, using the toilet, getting in and out of bath or eating) b. Housekeeping (such as help with meal preparation, cleaning, laundry and taking out the garbage) c. Transportation d. Shopping/errands e. Supervision f. Taking Medication g. Managing Money h. Other, please specify: 9 Revised 08/02/2005 Clients Initials 3. If services were not in place, would there be anything that would make it difficult for you to provide care? Yes No (If yes, discuss and note any factors that might limit caregiver) Caregiver's comments Possible factors include: Yes No a. Job b. Finances c. Family responsibilities d. Physical burden e. Emotional burden f. Caregiver's mental health g. Other Comments 10 Revised 08/02/2005 Clients Initials SECTION 3.5 MEDICATION REVIEW (OPTIONAL) A. MEDICATION USE (Ask client if you can see the medications so that you can verify frequency, dosage, etc. Include over the counter drugs like aspirin, laxatives, and vitamins. Some medicines may be refrigerated) 1. Are you taking any medicines? If so, could you show them to me so we can list their names and dosage? MEDICATION PRIMARY PRESCRIBING DOCTOR AND DIRECTIONS / STRENGTH/DOSAGE 2. Do you have difficulty remembering to take your medications? a. Yes b. DRUG COMPANY AND COST No (If necessary, prompt the client by asking if s/he is concerned about forgetting. What steps does s/he take to remember?) 3. Please list your drug allergies 4. Referral made 11 Revised 08/02/2005